The document describes several clinical scenarios involving patients presenting with various medical and psychological conditions. For each scenario, multiple choice response options are provided regarding the most appropriate action, diagnosis, or statement by the physician. The scenarios cover topics such as acute medical emergencies, psychiatric disorders, substance abuse, grief stages, personality disorders and more.

1. A 4-year-old girl is brought to the physician by her mother because of a fever for 1 day. The physician is more than 1
hour behind schedule because of two patient emergencies earlier that day. When he enters the room, the mother yells,
“Do you know how long we’ve had to wait? This is totally unacceptable!” It is most appropriate for the physician to
initially state which of the following?
(A) “I am frustrated, too, with being so far behind schedule.”
(B) “I hope my staff explained about the difficult patients who caused the delay.”
(C) “It must have been very difficult to be here for so long with a sick child.”
(D) “My office staff scheduled too many patients for today.”
(E) “Unfortunately, some patients demand more time than we scheduled for them.”
A 45-year-old man is admitted to the hospital because of chest pain for 1 hour. He has a sedentary lifestyle, and his diet
is high in fat and sodium. The diagnosis of acute angina is made, and the appropriate treatment is administered. After
the patient’s condition is stabilized, the physician recommends an exercise regimen and a low-fat, low-sodium diet.
Two weeks later, the patient returns for a follow-up examination. He indicates that he has not yet returned to work and
spends most of the day lying on the couch. He has not had any chest pain, shortness of breath, dyspnea with exertion, or
peripheral edema. Which of the following initial statements by the physician is most appropriate?
(A) “Are you afraid you might have a heart attack if you exercise?”
(B) “Are you doing any types of exercise other than channel surfing?”
(C) “Have you also not been following the diet I recommended?”
(D) “What do you think is interfering with your ability to resume activity?”
(E) “When would you like to start working on improving your health?”
A 46-year-old man comes to the physician for a follow-up examination. He underwent coronary artery bypass grafting
3 weeks ago. He works long hours daily as the head chef and owner of a restaurant. He has had a 14-kg (30-lb) weight
gain since opening his restaurant 3 years ago. He attributes this weight gain to “working around food all day, every
day.” He does not smoke cigarettes. His father had a myocardial infarction at the age of 60 years. The patient is 175 cm
(5 ft 9 in) tall and now weighs 102 kg (225 lb); BMI is 33 kg/m2. Physical examination shows no other abnormalities.
He tells the physician that he is afraid to cut down on his work hours because his business might suffer as a result, but
he says, “I don’t want to have a heart attack like my dad did.” Which of the following responses by the physician is
most appropriate?
(A) “The fact that you do not smoke cigarettes balances out your other risk factors, such as your weight and family
history.”
(B) “Given your family history, modifying other risk factors won’t have much impact.”
(C) “I suggest you have someone else run your business for the time being, so you can spend your days in a more
healthy environment.”
(D) “Let’s discuss some lifestyle changes, including weight loss, exercise, and decreased stress.”
(E) “Since the only risk factor for a myocardial infarction you can change is your weight, I suggest you initiate a
weight-loss program fairly soon.”
14. A 40-year-old woman with hypertension comes to the physician for a follow-up examination. Her blood pressure is
160/96 mm Hg. She tells the physician that she has been having difficulty being compliant with her medication
regimen and low-sodium diet. Which of the following responses by the physician is most appropriate?
(A) “I will go over the regimen and diet again to make sure you understand them.”
(B) “I’d like you to read these pamphlets on the risks of hypertension. You will then realize the seriousness of your
condition.”
(C) “If you don’t follow my recommendations, you could end up having a heart attack or stroke. You could also
become blind.”
(D) “Tell me the difficulties you’ve been having. Perhaps we can make your regimen and diet easier for you to follow.”
(E) “Unfortunately, if you do not follow your medication regimen you will die”

2. A 10-month-old boy is brought to the emergency department by his babysitter 1 hour after he was difficult to arouse
following a head injury. The babysitter says he hit his head after falling off a bed and that she could not wake him at
first when she found him lying on the floor. The patient is conscious and not in distress. Physical examination shows a
2-cm hematoma over the left parietal region of the head. There are ecchymoses in various stages of healing on different
body surfaces, including the buttocks and low back. Neurologic examination shows no abnormalities. When questioned
about the bruises, the babysitter replies, “He just seems to bruise easily. Maybe he has some sort of bleeding problem.”
After notifying the parents, the physician should do which of the following next?
(A) Ask the hospital social worker to obtain a criminal background check on the babysitter
(B) Have a court appoint a guardian for the child
(C) Notify child protective services of suspected abuse
(D) Refer the patient to a pediatric hematologist
(E) Register a formal complaint against the babysitter with the local police department
A 32-year-old woman comes to the emergency department after taking 40 1-mg tablets of alprazolam. She says that her
boyfriend threatened to leave her, and she feels “empty.” She drinks several six-packs of beer weekly and uses cocaine
daily. She has outbursts of rage whether or not she is intoxicated. Which of the following is the most likely personality
disorder?
(A) Antisocial
(B) Borderline
(C) Dependent
(D) Narcissistic
A 65-year-old man comes to the physician for a follow-up examination after the results of a bronchoscopy showed
squamous cell carcinoma. When the physician tells the patient the diagnosis, the patient becomes tearful and responds,
“No, you’re wrong! This must be a mistake. This can’t happen to me. Let’s do more tests.” This patient is most likely at
which of the following stages of grief?
(A) Anger
(B) Bargaining
(C) Denial
(D) Depression
A 45-year-old man is brought to the physician by his spouse. He has been drinking heavily since he was passed over for
a job promotion 3 days ago. He stayed in bed over the weekend. He has no personal history of psychiatric disorders and
no personal or family history of alcohol abuse. He is crying and states, “I can’t believe it,” when addressed. When
asked what he will do, he states, “I don’t know, but if I don’t go back to work tomorrow, I’ll lose my job.” Which of
the following is the most likely diagnosis?
(A) Adjustment disorder with depressed mood
(B) Bipolar disorder
(C) Dysthymic disorder
(D) Major depressive disorder
(E) Substance abuse
A previously healthy 18-year-old woman is brought to the physician for evaluation because of loss of appetite,
sleeplessness, and extreme irritability for 3 weeks. After missing many practices, she quit the college softball team that
she previously enjoyed. She often feels tired and has difficulty sitting still and concentrating on schoolwork. Her
menses occur at regular intervals. She weighs 50 kg (110 lb) and is 168 cm (5 ft 6 in) tall; her BMI is 18 kg/m2. Her
pulse is 74/min, respirations are 16/min, and blood pressure is 110/70 mm Hg. Which of the following is the most
likely diagnosis?
(A) Adjustment disorder with mixed disturbance of emotions and conduct
(B) Anorexia nervosa
(C) Attention-deficit/hyperactivity disorder
(D) Dysthymic disorder

3. (E) Major depressive disorder
A 32-year-old woman is brought to the emergency department because of fever, hallucinations, agitation, and
confusion for 8 hours. She has a history of alcohol, cocaine, and benzodiazepine abuse. Her temperature is 37.8°C
(100°F), pulse is 110/min, respirations are 16/min, and blood pressure is 150/90 mm Hg. Examination shows tremors
and telangiectasia. The lungs are clear to auscultation. There is a holosystolic murmur; the abdomen is tender, and the
liver edge is palpable 3 cm below the right costal margin. Rectal examination shows no abnormalities. Her serum
alkaline phosphatase activity is 200 U/L, serum ALT activity is 60 U/L, and serum AST activity is 90 U/L. Which of
the following is the most likely cause of this condition?
(A) Acute cocaine toxicity
(B) Alcohol withdrawal
(C) Benzodiazepine withdrawal
(D) Panic disorder
(E) Schizophreniform disorder
A 10-year-old boy is brought to the physician because of increasing behavior problems in school since starting 5th
grade 3 months ago. His teacher states that he is unable to sit quietly through a classroom period and frequently
disrupts the class and interrupts other children while they are talking. His parents report that he has always been an
active child and are concerned because he is inattentive when he runs or walks. During examination, he fidgets with his
hands and feet and is easily distracted from completing a task. Which of the following is the most appropriate
pharmacotherapy?
(A) Amitriptyline
(B) Fluoxetine
(C) Haloperidol
(D) Imipramine
(E) Methylphenidate
A 27-year-old woman is brought to the emergency department 1 hour after a friend found her barely arousable in her
disorderly apartment with a nearly starving cat. The patient appears extremely thin. Her pulse is 90/min, respirations
are 6/min, and blood pressure is 90/60 mm Hg. Physical examination shows small pupils, cracked lips, and bruises and
scratches over the upper extremities. Mental status examination shows mild obtundation, blunted affect, and slow,
incoherent speech. Which of the following is the most appropriate next step in management?
(A) Observation in a quiet darkened room
(B) Oral administration of chlorpromazine
(C) Intramuscular administration of naloxone
(D) Intravenous administration of haloperidol
(E) Intravenous administration of lorazepam
A 27-year-old man is brought to the emergency department by police 2 hours after threatening his next door neighbor.
The neighbor called the police after receiving a note demanding that she stop videotaping all of the activities in the
patient’s home or he would call the police. During the examination, the patient is cooperative. He explains that he has
lived in the neighborhood for 8 months. Three months ago, he noticed that his neighbor installed a new satellite dish
and says that since that time, she has been watching every move he makes. He reports no personal or family history of
psychiatric illness. He has not had changes in sleep pattern and performs well in his job as a car salesman. He appears
neatly dressed. Physical examination shows no abnormalities. On mental status examination, his thought process is
organized and logical. There is no evidence of suicidal or homicidal ideation or hallucinations. He says that he is not
suspicious of anyone other than his neighbor. Which of the following is the most likely diagnosis?
(A) Bipolar disorder
(B) Brief psychotic disorder
(C) Delusional disorder
(D) Major depressive disorder with psychotic features
(E) Schizophrenia

4. A 77-year-old man comes to the physician with his daughter for a follow-up examination to learn the results of
neuropsychological testing performed 1 week ago for evaluation of a recent memory loss. Results of the testing
indicated cognitive changes consistent with early stages of dementia. Three weeks ago, he was diagnosed with prostate
cancer and has shown signs of a depressed mood since then. Twenty years ago, he required treatment in a hospital for
major depressive disorder. His symptoms resolved with antidepressant therapy, and he has not taken any psychotropic
medication for the past 15 years. The patient’s daughter comes into the examination room before her father and asks
that the physician not tell her father any information that might be upsetting, given his vulnerability to depression. She
says she is concerned about what the results might be and how her father will handle them. The patient enters the room
soon after his daughter makes her request. Which of the following is the most appropriate initial physician statement to
this patient?
(A) “Because of your history of depression, I would like you to start on an antidepressant medication before we talk
any further about your neuropsychological testing.”
(B) “Before going over your test results, I’d like to hear how you have been doing. You have been through a difficult
time.”
(C) “I would like to talk with your daughter a bit about your test results, and then I will go over things with you.”
(D) “Your daughter is concerned about you. I think you need to see a psychiatrist before we go any further here.”
(E) “Your tests were inconclusive, and I would like to have you start on a medication to help with your memory as a
precaution
An 80-year-old man is admitted to the hospital for treatment of a burn that covers 20% of his
total body surface area. Two days after admission, his behavior has changed. He accuses the staff of
torturing him. He cannot recall why he was admitted to the hospital and is not oriented to date and place.
His wife says he was fine before the burns. What is the most likely diagnosis?
(A) Adjustment disorder
(B) Delirium
(C) Paranoid personality disorder
(D) Schizophrenia, paranoid type
(E) Dementia, Alzheimer type
A 52-year-old woman is admitted to the hospital because of breast cancer metastatic to the liver.
Her prognosis is poor. She begs her husband to stay with her at the hospital because she is afraid to be left
alone. Which of the following defense mechanisms best explains her behavior?
(A) Denial
(B) Displacement
(C) Regression
(D) Repression
(E) Sublimation